Adoption of vaginally assisted natural orifice transluminal endoscopic surgery for hysterectomy: A single tertiary experience.

BACKGROUND: Vaginal hysterectomy (VH) rate is declining despite being considered as the optimal minimally invasive option for hysterectomy with reduced operative time and length of stay compared with laparoscopic hysterectomy (LH). Vaginal assisted natural orifice transluminal endoscopic surgery hysterectomy (VANH) combines the advantages of both vaginal and endoscopic approach to surgery. AIMS: To report feasibility and early experience of a single surgeon adopting VANH at a tertiary Australian hospital. MATERIALS AND METHODS: Prospective review of the first 20 VANH cases with complete data set collected retrospectively including patient demographics, indication for surgery and perioperative outcomes. RESULTS: The median age of the first 20 participants was 51.5 years (47-57 years of age) and the median body mass index was 33.5 kg/m2 (27.8-38.3 kg/m2). The predominant indication was complex hyperplasia with atypia (12/20, 60%). The median parity was two (1-3) where four patients were nulliparous. The median blood loss was 125 mL (100-200 mL) with an operative time of 149 min (138-198 min) and median weight of the specimen of 181.5 g (66.5-219 g). The mean length of stay was 1.4 days (1-2 days). Five cases had conversion to laparoscopy and the majority (80%) occurred within the first ten cases. CONCLUSIONS: VANH is feasible but there is a learning curve to achieve competence in this technique, which requires adequate training in the early stages of adoption with careful case selection. Until further robust data is available to determine the clinical benefit and safety profile of VANH, patients should be carefully counselled and the decision on mode of hysterectomy be individualised.

Bilateral salpingectomy as an option of permanent contraception at time of caesarean section: A survey of practice.

BACKGROUND: Opportunistic bilateral salpingectomy during benign gynaecologic surgery is advocated as a risk-reducing strategy due to the inverse association of epithelial ovarian cancers observed in epidemiological studies in a low-risk setting. Currently, no formal guidance exists for permanent surgical contraception at time of caesarean section in Australia. AIMS: Our aim was to survey Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding bilateral salpingectomy compared to other procedures offered for permanent contraception at the time of caesarean section. MATERIALS AND METHODS: An online survey was utilised to collect clinician demographics, opinions, barriers, and justifications in regard to options of permanent surgical contraception at time of caesarean section. RESULTS: Bilateral salpingectomy was identified as the most effective method of permanent contraception at time of caesarean section. However, only 62% of respondents offer the procedure as a method of permanent contraception. The two most common reasons for clinicians to offer bilateral salpingectomy at time of caesarean section were evidence suggesting a link between the fallopian tube and gynaecological cancer (80%) and efficacy as a permanent form of contraception (16%). The primary barrier identified by 51% of respondents was perceived increased risk of surgical complications, followed by reasoning that it would not allow the possibility of future tubal reversal. CONCLUSION: This study identifies diverse opinions on surgical approach to permanent contraception at time of caesarean section and offered by clinicians of RANZCOG. Further research is required to establish safety profiles and short- and long-term risks of bilateral salpingectomy.

Laparoscopic Eradication of Deep Endometriosis With Segmental Rectosigmoid Resection and Bilateral Posterior Parametrectomy With Nerve-sparing "Touchless" Technique According to the "Negrar Method".

OBJECTIVE: To demonstrate nerve-sparing laparoscopic eradication of deep endometriosis with rectal and parametrial resection based on the Negrar method [1] using the "touchless" technique. DESIGN: Stepwise video case demonstration with narration. SETTING: Tertiary level endometriosis unit. The patient was a 28 year-old nulliparous patient referred for surgery with persistent dysmenorrhea, dyspareunia, and dyschezia despite medical management (progestin-containing hormonal pills). Preoperative ultrasound demonstrated bilateral endometriomas, diffuse adenomyosis, and 35 mm × 17 mm stenosing rectal nodule. Histopathology confirmed 60% stenosis of the rectum secondary to the endometriotic nodule up to submucosal layer with margins free of endometriosis. She was discharged 7 days postoperatively with no postoperative complications. INTERVENTIONS: Laparoscopic nerve-sparing eradication of deep endometriosis with segmental rectosigmoid resection and bilateral posterior parametrectomy [2] according to the "Negrar method" with nerve-sparing "touchless" technique, sliding the nerve bundles laterocaudally, and keeping intact the visceral pelvic fascia covering them, thus without direct contact with the nerves. CONCLUSION: In our experience, based on more than 3000 of these procedures [3], this nerve-sparing procedure, based on identifying the nerves and their laterocaudad dissection, without a direct impact on their fibers but just on their fascial envelopes has proven successful in lowering the rates of postoperative dysfunctions and neural impairment related to neuro-apraxia and edema that occurs by directly affecting them [1]. Although there are no robust data to demonstrate benefit of "touchless" nerve-sparing dissection techniques, neuro-apraxia from compression of neural fibers that has been observed can be minimized [1,4,5].

A novel approach using vaginal natural orifice transluminal endoscopic surgery to repair a symptomatic uterine isthmocele.

OBJECTIVE: To describe the first case of using a vaginal natural orifice transluminal endoscopic surgery approach to repair a uterine isthmocele. DESIGN: Stepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital Institutional Review Board approval. SETTING: Hospital. PATIENT(S): A 30-year-old (gravida 2, para 2) patient presented with symptoms of intermenstrual bleeding and secondary subfertility following 2 uncomplicated cesarean section deliveries (elective for breech and repeat). The patient had a transvaginal ultrasound (US) demonstrating an isthmocele with a defect of 8.1 × 7.0 mm with a myometrial thickness of 2 mm over the defect and proceeded to undergo surgery because of persistent symptoms. INTERVENTION(S): An anterior vaginal incision is made on the cervix from the 3 o'clock to 9 o'clock position after local anesthetic and adrenaline infiltration of the tissue. The vaginal epithelium was carefully dissected cephalad, although an attempt was made to maintain the uterovesical space and fold. A small (7 cm) V-path gel port was inserted into this uterovesical space and the gel port was affixed with a port connected to an insufflation stabilization bag to minimize the pressure fluctuations within the confines of a small operative space and help maintain visualization throughout. Under endoscopic view, the site of the isthmocele was identified using an endoscopic US probe and confirmed on 2 dimensional imaging. A monopolar hook with an inbuilt aspirator and suction function was used to incise over the isthmocele with a grasper used to dissect into this space. A Hegar dilator was used to delineate the cervical canal. Once the isthmocele was excised, the defect was reinforced and obliterated with a barbed suture whereas the Hegar dilator was in place to prevent inadvertent canal occlusion during suturing. Continuous suturing took place from the cephalad to the caudal directions in 2 layers. Once hemostasis was confirmed, the gel port was removed, and the vaginal epithelium was closed with interrupted sutures using a braided absorbable suture. The perioperative course and care were uneventful with the Foley catheter being removed 3 hours after surgery. The patient was discharged within 24 hours. A follow-up organized 6 weeks after surgery demonstrated obliteration and repair of the previously detected uterine isthmocele on the pelvic US scan. The patient also reported a resolution of symptoms at this postoperative visit. MAIN OUTCOME MEASURE(S): N/A. RESULT(S): N/A. CONCLUSION(S): Uterine-conserving surgical approaches to an isthmocele have been described, including vaginal, hysteroscopic, and laparoscopic (with and without robotic assistance) approches and laparotomy, with no single approach deemed to be superior to the others. The existing evidence is limited by the lack of uniformity in the definition and diagnosis of uterine isthmocele, consistency in indication for surgery, and small case numbers in published surgical series. Vaginal natural orifice transluminal endoscopic surgery provides a novel approach to this type of surgery, which may be potentially less invasive as the procedure is conducted outside the peritoneal cavity and combines the best vaginal approach to the surgical site with endoscopic magnification and capacity for microscopic dissection. This approach should be considered new and only in a clinically appropriate and carefully counseled patient.

Gastric Injury at Laparoscopy for Gynecologic Indications: A Systematic Review.

OBJECTIVE: This systematic review aims to identify causes of increased risk for and location and mechanism of gastric injury at laparoscopy for gynecologic indications and determine optimal management. DATA SOURCES: A prospectively registered systematic review (PROSPERO: CRD42021237999) was undertaken and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Web of Science, SCOPUS, and Google Scholar from 1960 to 2021. METHODS OF STUDY SELECTION: All study types were included involving female patients of any age with gastric injury at laparoscopy for gynecologic indication. TABULATION, INTEGRATION, AND RESULTS: A total of 6294 articles were screened, from which 67 studies were selected for a full-text review. Twenty-eight articles were included, which contained 42 cases drawn from 7 observational studies, 4 case series, and 17 case reports. Of these, 93% (39/42) were at the time of laparoscopic entry, with Veress entry technique used in 79% of these cases (31/39). Eighteen cases reported an entry point, with 77% (14/18) occurring at the periumbilical entry point and 11% (2/18) occurring at Palmer's point. Of the cases with reported etiology for gastric distention or displacement, 64% (9/14) were owing to anesthetic cause. The most common sites of gastric injury were on the anterior stomach wall (n = 8) and the greater curvature (n = 5). Among patients with reported management (32/42), a similar proportion were managed conservatively (11) when compared with repair through laparotomy (13) or laparoscopy (8). All injuries were detected intraoperatively with no reported short-term sequelae. CONCLUSION: This systematic review of the literature reveals that gastric injury at laparoscopy for gynecologic indications is a rare complication predominantly occurring during laparoscopic entry, most commonly at the periumbilical entry point. When detected intraoperatively, conservative management, laparoscopic, or open repair in the appropriate patient has been performed with no short-term sequelae. The limitations of this review include paucity of cases, detail, and timeline of publications.

A systematic review of diagnostic tests to detect pelvic floor myofascial pain.

INTRODUCTION AND HYPOTHESIS: Myofascial pain arising from pelvic floor muscles occurs in women with vaginismus, interstitial cystitis and endometriosis but is often overlooked. The aim is to examine alternative diagnostic tests to detect pelvic floor myofascial pain compared with standardized vaginal palpation of pelvic floor muscles as the reference test. METHODS: A systematic review was prospectively conducted (PROSPERO-CRD42020183092) according to PRISMA guidelines. Databases searched included Ovid Medline 1946-, Embase 1957-, Scopus 1960-, Cochrane Combined, Clinical trials, Google Scholar (top 200 articles), Web of Science, TRIP, BIOSIS, DARE, CINHAL, EmCare, PEDro, ProQuest and EBSCOhost up to July 2020. Articles were independently screened by two authors and assessed for bias using QUASDAS-2 tool. RESULTS: A total of 26,778 articles were screened and 177 were selected for full text review, of which 5 were selected for final analysis. Five studies included 9694 participants of which 1628 had pelvic floor myofascial pain. Only one study reported data to calculate sensitivities and specificities of the index test, which utilized a score of > 40 on the Central Sensitization Inventory to detect women with pelvic floor myofascial pain and revealed a sensitivity of 34.8% and a specificity of 84.9% compared to the reference test. CONCLUSIONS: This systematic review did not reveal any diagnostic test superior to the pre-defined reference test. There is a lack of consensus on the definition of pelvic floor myofascial pain and a lack of a validated diagnostic criteria which must be addressed to progress with meaningful research in this field.

Uptake of outpatient hysteroscopy in Australia using Medical Benefits Scheme data: Have we fallen behind?

BACKGROUND: Hysteroscopy is a safe procedure which allows both diagnosis and management of cervical and endometrial pathology. Improving Australian women's access to outpatient hysteroscopy would improve cost efficiency and allow women a quicker recovery, negating the need for a general anaesthetic. Increasing the Medicare renumeration for outpatient hysteroscopy could incentivise provision of outpatient hysteroscopy. AIM: We sought to review the trend and current uptake of outpatient diagnostic hysteroscopy in Medicare Benefits Scheme (MBS)-funded clinics within Australia. MATERIALS AND METHODS: A retrospective review of Australian MBS data from 1 January 1993 to 31 December 2020. RESULTS: Over the past 27 years, 1 319 909 hysteroscopies have been claimed from Medicare in Australia, with 39 958 (3.1%) claimed as an outpatient diagnostic procedure. Australian outpatient diagnostic hysteroscopy MBS item number use peaked in 1994 (5871 cases) representing 18.2% of all hysteroscopies claimed through the MBS that year. Uptake of the outpatient hysteroscopy item number rapidly declined after 1994 and in 2010, it represented 0.8% of all hysteroscopies claimed (426 of 49 618) and has remained below <0.5% from 2010 to 2020. CONCLUSIONS: The lower Medicare rebate and lack of recognition of the importance of outpatient hysteroscopy has likely been a driving factor in continuing inpatient hysteroscopy. Incentivised government funding has been successfully utilised in the UK to improve outpatient hysteroscopy access. This MBS data suggests that Australia has not progressed in outpatient hysteroscopy access and support a change in the current funding model to assist in supporting the uptake of outpatient access.

Spontaneous Pregnancy after Total Bilateral Salpingectomy: A Systematic Review of Literature.

OBJECTIVE: To assess the occurrence of spontaneous pregnancy after a history of total bilateral salpingectomy (BS). DATA SOURCES: A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching MEDLINE, Embase, Google Scholar, PubMed, SCOPUS, and Web of Science from database inception to February 20, 2020. METHODS OF STUDY SELECTION: We included women with a history of total BS for any indication with subsequent spontaneous pregnancy. Excluded were women who had a history of incomplete/partial salpingectomy or tubal occlusion, who had pregnancy after assisted reproductive technology, and whose pregnancy was not appropriately confirmed via beta-subunit of human chorionic gonadotropin or ultrasound. TABULATION, INTEGRATION, AND RESULTS: The systematic search retrieved 1942 articles; 39 studies were potentially eligible, and their full texts were reviewed. A total of 4 case reports were included. Total BS had been performed for other indications than permanent contraception in all cases. Pain was the most common presenting symptom. All 4 pregnancies were intrauterine in location. Treatment was based on desire to continue pregnancy and hemodynamic stability. CONCLUSION: Spontaneous pregnancy after total BS is exceedingly rare. The present data suggest that it is reassuring to offer total BS as a form of permanent contraception. Prospective data are warranted to ascertain short- and long-term effects of total BS for permanent contraception including its efficacy.

A retrospective cohort study of tubal occlusion or salpingectomy for permanent contraception in Australia.

BACKGROUND: Laparoscopic permanent contraception was previously accomplished most commonly using tubal occlusion procedures. Bilateral salpingectomy (BS) has recently been introduced as an alternative due to possibly superior contraception and greater protection against ovarian cancer. AIMS: The aim of this study is to assess uptake, feasibility and perioperative outcomes of laparoscopic BS as an alternative to tubal occlusion in Australia. MATERIALS AND METHODS: A retrospective review of permanent female contraception at two Australian hospitals from January 2014 through December 2020 was performed. The primary outcome was the uptake of BS. Secondary outcomes were feasibility, procedure length, number of ports, perioperative complications and admission length. RESULTS: A total of 414 women were included; 92 (22.2%) underwent BS and 322 (77.8%) underwent tubal occlusion. There was a slow uptake of BS from 2014 to 2016 (0-3.2%), with a steep uptake from 2017 to 2020 (30-72%) (P = 0.001). Procedure feasibility was 96.8% (62/64) and 99.3% (282/284) for BS and tubal occlusion group, respectively (P = 0.64). BS procedure time was longer by 23 min (P < 0.001). Three or more surgical ports were used in all cases of BS compared to 4.5% of the tubal occlusion group (P < 0.001). There were no intraoperative complications. There were nine and six postoperative complications in the tubal occlusion versus BS group, respectively (P = 0.10). The median admission length was 7.1 (tubal occlusion) versus 7.3 (BS) h (P = 0.10), with five unintended overnight admissions. CONCLUSION: BS is an increasing choice for permanent contraception. It appears equally feasible as tubal occlusion but typically requires a longer procedure time and a minimum of three surgical ports.

A Delayed Case of Uterine Perforation with Omental Adhesions.

Uterine perforation is an uncommon but potential risk during all intrauterine procedures. We display a set of images from ultrasound, hysteroscopy, and laparoscopy, as well as a video from laparoscopy, pertaining to a case of uterine perforation with omental adhesions. The complication was diagnosed several months after dilatation of the cervix and curettage of the uterus following a missed miscarriage. This is a rare but serious complication following a commonly performed procedure and the case highlights the importance of investigating new symptoms even after a seemingly uncomplicated procedure.

Systematic Review and Meta-Analysis on Hysterectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Compared to Laparoscopic Hysterectomy for Benign Indications.

(1) Objective: We aimed to report an update of the systematic review and meta-analysis by Baekelandt et al. (2016). (2) Method: We followed PRISMA guidelines to perform this systematic review. We searched MEDLINE, EMBASE, CENTRAL and additional sources and aimed to retrieve randomised controlled trials (RCTs), controlled clinical trials (CCTs) and prospective/retrospective cohort studies in human subjects that allowed direct comparison of vNOTES to laparoscopy. (3) Results: Our search yielded one RCT and five retrospective cohort trials. Pooled analysis of two subgroups showed that, compared to conventional laparoscopy, vNOTES is equally effective to successfully remove the uterus in individuals meeting the inclusion criteria. vNOTES had significantly lower values for operation time, length of stay and estimated blood loss. There was no significant difference in intra- and postoperative complications, readmission, pain scores at 24 h postoperative and change in hemoglobin (Hb) on day 1 postoperative.

Day 1 to day 4 serum hCG change in predicting single-dose methotrexate treatment failure for tubal ectopic pregnancies.

OBJECTIVE: To determine if changes in Day 1 to Day 4 serum human chorionic gonadotropin (hCG) levels can predict treatment failure of single-dose methotrexate (MTX) in medical management of tubal ectopic pregnancies (EP). STUDY DESIGN: This retrospective cohort study was conducted at a tertiary level hospital. Files were reviewed for all women who received at least one dose of 50 mg/m2 intramuscular MTX for treatment of ultrasound-confirmed tubal EPs between 2013 and 2018. "Treatment failure" is defined as needing additional MTX or surgery to manage the EP. The primary purpose is to establish a threshold percentage change in Day 1 to Day 4 (Day 1/4) hCG that best predicts treatment failure, with clinically and statistically significant sensitivity and specificity, based on receiver-operator characteristic (ROC) analysis. RESULTS: 252 files were reviewed, with 108 included for final analysis. 17% of cases required a second dose of MTX and 12% required surgery to manage the EP. Women in the treatment failure group had significantly higher median hCG levels on Day 1, 4 and 7, but were otherwise similar to women who were successful in age, parity, history of previous EP, and EP size. ROC curve analysis of Day 1/4 hCG demonstrates that ≥5% rise best predicts treatment failure with sensitivity 68% (95% confidence interval [CI] 49-83%), specificity 69% (95%CI 56-78%), and AUC 0.77 (95%CI 0.68-0.86, p < 0.001). The positive predictive value is 46% (95%CI 36-56%) and negative predictive value is 84% (95%CI 75-90%). In comparison, ROC analysis of Day 4 to Day 7 hCG demonstrates that a drop of ≤17% best predicted failure, with sensitivity 83% (95%CI 64-94%), specificity 82% (95%CI 71-90%), and AUC 0.90 (95%CI 0.84-0.96), p < 0.001. CONCLUSION: This study suggests that ≥5% rise in Day 1/4 serum hCG levels could potentially predict treatment failure of single-dose MTX for tubal EPs, and that conversely, <5% rise or any drop in Day 1/4 hCG levels can reliably predict treatment success. Clinicians could consider factoring-in Day 1/4 hCG changes during the course of medically managing patients. They must bear in mind, however, that acting on the Day 1/4 hCG change would lead to increased interventions.

Spontaneously Ruptured Dermoid Cysts and Their Potential Complications: A Review of the Literature with a Case Report.

Spontaneous ruptures of dermoid cysts are a rare occurrence due to their thick capsules. This is the first systematic review on spontaneously ruptured dermoid cysts. A comprehensive literature search was performed from PubMed, Google Scholar, and MEDLINE. The cases were analysed for patient demographics, presenting signs and symptoms, imaging modalities used, management methods, and outcomes. The majority of cases report an idiopathic cause with symptoms of abdominal pain, distension, and fever. Computed tomography is the most accurate in detecting ruptured dermoid cysts. We also report a case of a 66-year-old who presented with sudden abdominal pain and a low-grade temperature. Imaging showed a 10 cm well-circumscribed hyperechoic mass consistent with a dermoid cyst with no suggestive signs of rupture. She was planned for a laparoscopic bilateral salpingo-oophorectomy. However, intraoperatively, a ruptured dermoid cyst was found with bowel adhesions and chemical peritonitis as cyst contents covered the entirety of the intra-abdominal cavity. Her operative course was complicated by inadvertent iatrogenic small bowel injury, unsuccessful laparoscopy, needing conversion to laparotomy. Despite their benign nature, complications from ruptured dermoid cysts include peritonitis, bowel obstruction, and abscesses. Surgical management by both laparoscopy and laparotomy is successful, with laparotomies more likely to be performed. Complications have mostly no long-term sequelae.

Confounding effect of ethnic diversity on booking-in body mass index and prevalence of gestational diabetes and hypertensive disorders in pregnant women in western Sydney 1997-2016.

BACKGROUND: Maternal obesity is a key risk factor for morbidity in pregnancy. Accurate data on trends in obesity are required in high-risk populations such as in western Sydney to implement effective policy. AIMS: This study examines multi-site public hospital data on maternal ethnicity, body mass index (BMI), gestational diabetes mellitus (GDM) and hypertension across 20 years in Western Sydney Local Health District (WSLHD). MATERIALS AND METHODS: This is a retrospective cohort study of all women who delivered a live birth beyond 20 weeks at Westmead, Blacktown and Auburn Hospitals (WSLHD) between 1 January 1997 and 31 December 2016. RESULTS: There were 112 308 pregnant women included. Between 1997 and 2006, mean booking-in BMI climbed from 24.9 (median 23.9) to peak at 26.2 (24.9). It then fell to 25.3 (24.1) in 2012 before rising to 25.6 (24.4) in 2016. Rates of hypertensive disorders changed little over the period, with a small fall in pre-eclampsia. In contrast, there was a progressive upward trend in the prevalence of GDM, accelerating considerably after 2010. These trends were associated with a shifting ethnic profile with proportions of Australia/New Zealand-born women falling from 56.9% to 36.8%, while those from South Asia increased from 4.5% to 26.3%. CONCLUSIONS: Western Sydney booking-in BMI fluctuated between 1997 and 2016, reaching its peak in 2006. Despite this, rates of GDM progressively rose, with one in six mothers in western Sydney now diagnosed with some form of the condition. Both patterns are associated with a notable shift in the ethnic profile of patients booking-in to antenatal care in the region.

Elevated CA 125 in a CASE of Leaking Endometrioma.

Extremely elevated CA 125, usually suggestive of ovarian malignancy, can be found in physiological or benign conditions such as endometriosis. We present a case of an extremely elevated serum CA 125 level in a patient with stage four endometriosis and bilateral unruptured ovarian endometriomas, with evidence of leakage unilaterally. To avoid costly and unnecessarily invasive tests and procedures it is important to consider the differential diagnosis of endometriosis and/or leaking endometrioma in patients with a profoundly elevated CA 125 level.

A Vaginal Angiomyofibroblastoma as a Rare Cause of a Prolapsing Vaginal Mass: A Case Report and Review of the Literature.

INTRODUCTION: Angiomyofibroblastoma (AMFB) is a rare, benign, mesenchymal cell tumour which presents as a slow-growing mass. It is most commonly seen in the vulva and is often mistaken for Bartholin's abscess. It is histologically diagnosed by the presence of stromal cells intermingled with small blood vessels. It is morphologically similar to cellular angiofibroma and aggressive angiomyxoma, the latter of which is locally invasive and has a possibility of metastasis and a high risk of local recurrence. There is one reported case of an AMFB undergoing sarcomatous transformation. CASE REPORT: We report a case of a multiparous, 36-year-old woman with an anterior vaginal mass which was inappropriately treated as a vaginal prolapse prior to definitive surgical management. This is only the second reported case of an AMFB presenting as a prolapsing mass.

A Case of Placenta Percreta Managed with Sequential Embolisation Procedures.

BACKGROUND: The incidence of morbidly adherent placenta, including placenta percreta, has increased significantly over recent years due to rising caesarean section rates. Historically, abnormally invasive placenta has been managed with caesarean hysterectomy; however nonsurgical interventions such as uterine artery embolisation (UAE) are emerging as safe alternative management techniques. UAE can be utilised to decrease placental perfusion and encourage placental resorption, thereby reducing the risk of haemorrhage and other morbidities. CASE: We describe one of the very few reported cases of placenta percreta which was successfully treated primarily with sequential artery embolisation. Our patient underwent four embolisation procedures over a period of 248 days, with no major morbidity or complications. CONCLUSION: Repeat UAE may be a beneficial primary management modality in cases of placenta percreta with bladder involvement.

The Great Divide: Country of birth as a risk factor for obstetric anal sphincter injuries.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) can complicate up to 6% of births and are a major contributor to preventable maternal morbidity. Asian women have a risk of third and fourth degree perineal tears up to four times greater than women of other ethnicities in the same community, but the lack of differentiation of Asian women into regional groups has limited insight into the reasons behind their increased risk. AIMS: To investigate risk of OASIS associated with country of birth. METHODS: This was a retrospective cohort study of all women with a singleton, nulliparous pregnancy who delivered vaginally by spontaneous vaginal birth or an instrumental delivery between 1 January 2009 and 31 December 2015. The demographics of women who experienced OASIS were compared with those women who had minor perineal trauma. RESULTS: From January 2009 to December 2015 there were 10 750 singleton, nulliparous and natural vaginal birth (NVB), forceps or vacuum deliveries. Of these deliveries, 581 (5.4%) werehad third degree tears and 36 (0.3%) fourth degree tears. Women born in South Asia were at a much higher risk of OASIS than other groups, including women born in other Asian countries, compared to the Australian/New Zealand cohort. One in every 10 nulliparous South Asian women having a singleton vaginal or instrumental delivery will sustain an OASIS. CONCLUSIONS: Our study further confirms the role of Asian ethnicity in the risk of OASIS, and is the second to confirm that South Asian women are at a dramatically increased risk.

Antepartum uterine rupture at 29†weeks gestation following unilateral salpingectomy and review of literature.

Antepartum uterine rupture following salpingectomy is a rare condition and is associated with high fetal and maternal mortality and morbidity. We illustrate a 33-year-old primigravida who presented with abdominal pain at 29 weeks of gestation. Her previous obstetric history included a ruptured right ectopic pregnancy for which she underwent laparoscopic salpingectomy with no breach of uterine cavity. Her antenatal care had otherwise been unremarkable. Following admission for undetectable fetal heart, ultrasound and CT demonstrated an extrauterine fetus at the right adnexal region with free fluid consistent with intra-abdominal haemorrhage. An exploratory laparotomy was performed which revealed a uterine rupture at the right cornua with the extruded fetus en caul. The fetus was delivered and the uterus repaired in three layers. The patient made an uneventful postoperative recovery and was discharged 5 days following surgery. We review the current literature including the evaluation and management of this rare condition.